Pre-settlement funding application
Tel: (718) 465-2200
Fax: (718) 464-6505
Email: info@ifundcashnow.com
Please fill out the form below:
Amount of Advance Requested: $
Name of Claimant:
Street Address:
City, State & Zip Code:
Date of Birth:
Contact Numbers:
Email Address:
Prior Funding:
Yes
No
If Yes:
Date:
Amount: $
With Whom:
Case Type:
Auto Accident
Work related injury
Slip/Trip Fall
Premises Liability
Other
Required Documents
Police Report:
Doctor's Report:
MRI:
Bill of Particulars:
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Date of Accident:
Description of Accident:
Description of Injuries:
Does the claiment have any pre-existing conditions to same body parts?
Yes
No
Describe:
Did the claimant ever have prior losses or injuries?
Yes
No
Date of accident(s) and what injuries:
Be specific of the name of carrier of third party defendant with policy limits:
Name of Plaintiff's Counsel:
Phone Number:
Email Address:
